From the Guidelines
The patient should undergo an exploratory laparotomy as the most appropriate treatment, given the high suspicion of acute appendicitis with possible complications such as perforation or abscess formation, as indicated by the Alvarado score greater than 7, fever, toxicity, and elevated white blood cell count of 22,000 1.
Clinical Presentation and Diagnosis
The patient's presentation with right lower quadrant (RLQ) abdominal pain, guarding, fever, and a high white blood cell count is highly suggestive of acute appendicitis. The Alvarado score, which is greater than 7 in this case, further supports this diagnosis with a high probability (>90%) 1.
Importance of Immediate Surgical Intervention
Given the clinical signs of peritoneal irritation (guarding), significant inflammatory response or infection (fever, leukocytosis, and toxic appearance), immediate surgical intervention is warranted rather than further diagnostic imaging or conservative management 1.
Preoperative Management
Preoperatively, the patient should receive:
- Intravenous fluids to ensure hydration
- Broad-spectrum antibiotics, such as a combination of ceftriaxone 1-2g IV and metronidazole 500mg IV, as recommended for pre-operative management in acute appendicitis 1
- Appropriate pain management
Surgical Approach
The surgeon would typically perform an appendectomy during the laparotomy. Laparoscopic appendectomy is suggested for elderly patients due to reduced length of stay, morbidity, and costs, but the decision should be based on the patient's overall condition and the surgeon's expertise 1.
Postoperative Care
Postoperative management should include monitoring for signs of complications and administering post-operative broad-spectrum antibiotics if indicated, especially in cases of complicated appendicitis 1. The duration of antibiotic therapy should be based on clinical and laboratory criteria, such as fever and leucocytosis, but typically ranges from 3 to 5 days 1.
From the Research
Diagnosis and Treatment of Acute Appendicitis
The patient's symptoms, including right lower quadrant (RLQ) abdominal pain, guarding, fever, and elevated white blood cell count (WBCs 22000), along with an Alvarado score > 7, suggest acute appendicitis 2.
Treatment Options
- Surgical Management: Laparoscopic appendectomy is a common treatment for acute appendicitis, with a success rate of approximately 70% for uncomplicated cases 2.
- Antibiotics-First Approach: Broad-spectrum antibiotics can be used to treat uncomplicated acute appendicitis, but the presence of certain CT findings, such as appendicoliths or a dilated appendix, may indicate a higher risk of treatment failure 2.
- Imaging Studies: CT scans can help identify patients who are more likely to benefit from surgical management, while ultrasonography and MRI may also be used to diagnose appendicitis 3.
- Laparoscopic Drainage: In cases where an intraabdominal abscess has formed, laparoscopic drainage may be a safe and effective alternative to open laparotomy or percutaneous drainage 4.
Recommendations
Based on the patient's symptoms and Alvarado score, surgical management, specifically exploratory laparotomy or laparoscopic appendectomy, is likely the most appropriate treatment option 2, 5. However, the decision to operate should be made on a case-by-case basis, taking into account the patient's overall health and the presence of any high-risk CT findings.